The PRISM Project: Promoting
Realistic Individual SelfManagement Among Urban and
Rural Patients with Diabetes*
Elizabeth L. Ciemins, PhD, MPH
Valerie Caton, NP, MSN
Patricia J. Coon, MD
Center for Clinical Translational Research
Billings Clinic
June 29, 2009
*Funding support from NIH/NIDDK Grant # 5 R18 DK065787-03
Health Care, Education and Research
Background: Diabetes Disease
Management
• Currently in the midst of an “epidemic”1
• ~24
million people affected in U.S. or 8% of population (2007)
• Sixth leading cause of death (2006)
• 48.3 million cases projected in 2050
• High health expenditures: $174 billion 2007
• Care management guidelines exist; adherence still low2
• Risk Factor
Management – BP, HbA1C, Lipids
• Preventive Screening – Eye, Foot, Renal
1 Centers
for Disease Control and Prevention 2007 Diabetes Fact Sheet: www.cdc.gov/diabetes, Accessed June, 2009; 2007.
to ADA Standard of Care by Rural Health Care Providers. Coon, P, Zulkowski, K. Diabetes Care 25(12):2224-2229, 2002.; Standards of medical
care in diabetes--2009. Diabetes Care 2009;32 Suppl 1:S13-61.
2Adherence
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Study Objective
• Evaluate the effectiveness of an NP-led multidisciplinary team approach to diabetes selfmanagement on achieving ADA guidelines for
diabetes disease control, patient satisfaction and
patient self-management in the urban and rural
primary care setting.
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Methods: Intervention
• NP-led team approach
• Team:
–
–
–
–
NP Diabetes Specialist
Certified Diabetes Educator Nurse
Registered Dietician
Diabetes Life Coach (Master’s level Social Worker)
• Provided intensive clinical, educational,
psychosocial patient-driven care
• Face-to-face (urban) or Telemedicine (rural)
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Methods: Intervention
•
•
•
•
Appointments with 1-2 providers, e.g., NP & MSW
Focus on motivational interviewing
Weekly team meetings
Support groups:
– Educational Support Group
– ‘Create Your Weight’
– Women’s Self-Esteem Group
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Methods: Study Design
• Five-year study: 9/1/04 - 7/31/09
• Partial randomized control design
• Urban control patients vs. urban and rural
intervention patients
– Baseline
– 1-year, 2-year, 3-year post-intervention
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Methods: Study Participants
• Participants:
–
–
–
–
259 adult patients
Type 2 diabetes mellitus (DM)
At least one uncontrolled risk factor (HbA1c, BP or LDL-C)1
Seen by PCP in past year
• Study Sites:
– One urban primary care clinic:
• Part of community-owned, not-for-profit medical foundation
• 48 PCPs who manage ~5,000 diabetes patients
– Five rural primary care clinics in Eastern Montana (next slide)
• 2 to 9 providers per site serving 30 to 300 diabetes patients
1Standards
of medical care in diabetes--2009. Diabetes Care 2009;32 Suppl 1:S13-61.
Health Care, Education and Research
Study Sites
Health Care, Education and Research
Methods: Outcomes
• Control of Vascular Risk Factors:
– HbA1c < 7%
– BP < 130/80 mm Hg
– LDL cholesterol < 100 mg/dL
• Receipt of Annual Preventive Screening Exams:
– dilated eye and monofilament foot exams
– microalbumin/creatinine ratio (renal)
• Patient
- Satisfaction
- Self-management (self-report: adherence to
diet, exercise, blood glucose monitoring)
- Barriers to self-management
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Methods: Data Collection
• When:
– 1, 2, and 3 year historic
– Baseline, 1, 2, and 3 year post-intervention
• What:
– In person assessments: MMSE, QOLRS, SF-12,
CESD, DKQ, Satisfaction, Readiness to Change
– Paper and electronic chart review: clinical,
demographic, laboratory, and utilization data
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Results: Patient Demographics
Patient Demographics: Treatment vs. Control (n=259)
Total
Tx-Urban
n
%
83
28%
66%
Tx-Rural
n
%
109
37%
63
58%
Control
n
% p-value
67
23%
Female
55
Age (mean)
63
Referring Provider Specialty
1 IM
2 FP
3 Cardiology
66
17
0
80%
20%
0%
17
81
0
16%
74%
0%
50
15
1
75%
22%
1%
<.0001
Referring Provider Specialty
1 MD
2 NP
3 PA
76
2
5
92%
2%
6%
84
4
10
77%
4%
9%
63
1
2
94%
1%
3%
0.341
Mean Years Since DM Dx
7.9
Diagnoses
HTN
Dyslipidemia
Depression
64
67
22
61
68
69
23
55%
60
6.8
77%
81%
27%
37
0.385
7.6
62%
63%
21%
50
57
17
0.332
0.361
75%
85%
25%
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0.454
0.040
0.887
Proportion of patients with 2 or more controlled DM risk
factors* (n=259; p=.02)
75%
70%
70%
67%
Tx-Urban
Tx-Rural
Control
Percent Controlled
65%
60%
58%
55%
56%
50%
45%
46%
40%
38%
37%
35%
45%
44%
30%
Pre-PRISM
1 Yr Post-PRISM
2 Yr Post-PRISM
Study Time Period
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Proportion of patients with controlled risk factors 1 year post-PRISM
who were not in control at baseline, by risk factor (n=118)
53%
50%
Lipids (p=.03)
A1C (n.s.)
BP (p=.05)
49%
46%
45%
41%
40%
36%
35%
30%
30%
27%
20%
10%
0%
Tx-Urban
Tx-Rural
Cntrl-Urban
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Patients receiving all three preventive exams (eye, foot, renal)
(n=142; p=.05)
85%
Percent Patients
75%
Tx-Urban
Tx-Rural
Control
70%
74%
65%
55%
45%
50%
44%
45%
42%
38%
35%
35%
31%
25%
Baseline
1 yr post
Study Time Period
2 yr post
Diabetes Care Patient Satisfaction (n=141)
Tx-Urban
Satisfaction:
Very satisfied with diabetes care I receive (n=144)**
The diabetes care I received last few years is just about perfect (n=141)**
Communication:
I have been kept informed about next steps of diabetes care (n=136)**
Other health care provided has been up-to-date, current tx and test results (n=102)*
Satisfied with communications among different health care providers (n=128)**
Self-Efficacy:
Know who to ask when I had questions about my health (n=135)**
Feel good to excellent about managing my diabetes (n=111)**
Symptoms:
In past 6 months, my diabetes symptoms are somewhat or much better (n=131)**
↑ OR ↓
%∆
Tx-Rural
↑ OR ↓
%∆
Control
↑ OR ↓
%∆
↑
↑
97%
54%
↑
↑
200%
70%
↑
↑
44%
25%
↑
↑
↑
85%
67%
49%
↑
↑
↑
57%
30%
52%
↑
↑
↓
50%
16%
-6%
↑
↑
52%
74%
↑
↑
54%
68%
↓
↑
-7%
4%
↑
115%
↑
74%
↓
-7%
* p <.10; limited to subjects with data in both time periods
** p <.05; limited to subjects with data in both time periods
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Patient Self-Report: Checks Blood Glucose Correctly Most of the Time
(n=129; p=.05)
70%
76% ↑
60%
Pre-PRISM
Post-PRISM
97% ↑
Proportion Patients
14% ↑
50%
40%
30%
20%
10%
0%
Tx-Urban
Tx-Rural
Treatment Group
Control
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Summary
• PRISM had positive impact on improved risk factor
control, preventive care, patient satisfaction, and
diabetes patient self-management in urban and rural
areas
• However, appears less effective in rural patients
possibly due to:
– Communication issues/ Provider turnover
– Technology issues
• Telemedicine an effective and satisfactory means of
communication for rural patients1
• PRISM team identified barriers to self-management in
both urban and rural patients
1Ciemins
EL, Holloway B, Coon PJ, McCloskey-Armstrong T, Min SJ. Telemedicine and the Mini-Mental State
Examination: Assessment from a distance. Telemedicine and e-Health, 2009;15(4): 325-327.
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Implications
• Model of care provides viable alternative to
traditional one-on-one patient-provider
encounter, particularly in urban settings
• Rural clinics may need modification of
model, e.g., Shared Medical Appointments,
to encourage team participation and
involvement by rural PCPs
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